African Women’s Clinics: management of women with FGM/C

Women who have undergone FGM/C need sympathetic and sensitive management by clinicians.

It’s unfortunate that some campaigners appear not to understand this as they advocate for Social Care involvement, alongside midwives, in ante-natal clinics. This is likely to undermine the trust that women have developed in the long established and well used African Women’s Clinics in the UK.

This conversation with Dr Nawal Nour, an Obstetrician/Gynaecologist  in Boston, USA demonstrates her deep understanding of FGM/C and her empathy with patients who’ve undergone it. She gives excellent advice to professionals regarding how women, who have undergone the practice, should be dealt with in clinical practice.

A CONVERSATION WITH NAWAL NOUR; A Life Devoted to Stopping The Suffering of Mutilation. By CLAUDIA DREIFUS

BOSTON— In all the vast territory of the American health care system, there is nothing quite like the African Women’s Health Practice of the obstetrics and gynecology department at Brigham and Women’s Hospital here.

Every Friday, dozens of African women immigrants, now living in the area but still wearing the brilliant gowns of their native countries, come here for help with their medical problems. Many are seeking not just routine care in the specialty, but treatment for special gynecologic conditions related to female circumcision.

The ritual, which is also called female genital mutilation, is performed on young girls in many parts of Africa.

This unusual clinic is the brainchild of Dr. Nawal M. Nour, 34, a Sudanese-born, Harvard-trained gynecologist whose 1988 Brown University undergraduate thesis was ”The Emancipation of the Egyptian Woman.”

A crusader against female circumcision, Dr. Nour founded the clinic to help women who had been mutilated and to give her a platform to organize doctors and other professionals against the ritual.

On a recent cheery afternoon, when it seemed as if all of Boston was out along the Charles River enjoying the warm sun, Dr. Nour sat in her cubbyhole of an office at the Brigham and told how battling female circumcision had become her life’s passion.

Q. When did you first become aware of female circumcision?

A. Early. I grew up in the Sudan, Egypt and Great Britain, and so, for as long as I can remember, I was aware of it. My father is Sudanese. He was an agronomy professor and my mother is American. My parents were very influential. My father spoke out against it.

At school, I remember the girls saying: ”I was circumcised. Have you been?” I remember one girl saying she’d been circumcised and that it hurt, but it was a good thing because now she was a woman.

The practice troubled me, but I was also intrigued by it because it’s so horrible — and yet, it continues. As a child, I couldn’t understand why people would do something that wasn’t good for them. I think I became a physician so that I could find an effective way to attack it.

To this day, I get e-mails from schoolmates who write: ”You were always talking about this practice. I remember in the 10th grade, you brought up this issue.”

Q. How did this African women’s clinic begin?

A. In 1995, after I began my residency here, I started attracting patients from the Sudan, Ethiopia, Somalia and West Africa. I became known in the immigrant community around Boston as that ”African woman doctor” at Brigham and Women’s Hospital. Most of these women who came to me, obviously, had undergone female circumcision. So eventually, I went to people from the immigrant community and asked, ”Would you like for me to open an African clinic for Africans?” People were very excited. We did a focus group study and asked where they wanted this clinic — West Roxbury, Mission Hill? People wanted to go to the Brigham. They felt that this was where the wealthy Americans go and they should go to the same hospital.

Q. What kinds of clinical problems do your circumcised patients bring to you?

A. The major complications are seen on women who have undergone Type 3 circumcision. Type 1 removes the clitoris — this is common in Ethiopia. Type 2 excises the clitoris and the inner vaginal lips, which may end up fusing together.

Type 3 is removing the clitoris, the inner lips, the outer lips, then sewing everything together, leaving only a very small opening for urination and menses. This is mainly done among Somalis and Sudanese and in parts of West Africa. Female circumcision, you see, is nothing like what we know as male circumcision. In the latter, the foreskin is removed from the penis. With female circumcision, we have the equivalent of the penis being removed.

The women who’ve undergone Type 3 can have scarring problems and problems with their menses. Some of them have terrible trouble having sex with their husbands, as you can imagine.

It’s still shocking to me. This morning, I saw an 18-year-old whose opening was about dime size. I saw a woman the other week who was pregnant and had a pencil-sized opening. One couldn’t help but wonder how she’d managed to even get pregnant.

Q. Can some of this be solved by plastic surgery?

A. If the clitoris has been removed, it cannot be returned. But sometimes, when we do a procedure which opens up the scar tissue from the Type 3 circumcision the end result can look very good. It can look like new external lips have been formed. The women I’ve operated on are very pleased with that. They have less pain in intercourse and with their menses. It allows them to urinate quite easily, which often wasn’t the case before.

If a patient is considering getting pregnant and she has a very small opening as a result of the circumcision, I encourage her to be opened up. If she is coming in with chronic urinary tract infections, pain on intercourse or pain in menses, I often suggest it, too.

Q. Since you’ve had the clinic, have you gained any insight on a question you asked as a young woman: why does female circumcision persist?

A. I think it persists for complex reasons. Some people perpetuate it because they say that religion requires it, though that’s wrong. Islam never stated that girls should be circumcised. Others say they do it to make sure that their daughters will be marriageable. Still others argue that it’s necessary to maintain female chastity. I find that people do it because of a deeply ingrained belief that they are protecting their daughters. This is not done to be hurtful, but out of love. The parents do it because they think this is necessary to ensure that their daughters will get married. They love their children. These are the same parents who in time of war or famine, will give up their food so that the children will be fed.

One of the things our clinic tries to do is to educate American health care providers about the practice so that they can take better care of these women, when they come across them. And then, I try to educate the women to prevent the practice from being perpetuated in the U.S. and to try to prevent them from sending their daughters home to be circumcised there.

Q. In 19th century America, women were castrated and clitorectomized as a treatment for ”hysteria” and ”eroticism.” These operations, some historians suggest, were often used as a means of social control. Is the same true in contemporary Africa?

A. It’s a very difficult question to answer. Some would argue that, of course, it is a means of social control over women. But the fact is that the people who are perpetuating the practice are usually the women themselves. That’s why I think one of the things that must happen in Africa is that there should be dialogue between men and women. The men are not involved in it. It’s ”a woman’s thing.” There needs to be much more dialogue on how this affects a woman’s life.

Q. How likely is it that an American gynecologist will ever see a circumcised woman?

A. People in middle America may not see so much of it, but doctors in Portland, Ore., Washington, D.C., New York City, Seattle, Minnesota and parts of California are likely to. Those are the places where immigrants are going from Africa. There are at least 12,000 Somalis in Boston.

Q. What do your patients tell you about their experiences with the American health care system?

A. They often speak of going to a health care provider with abdominal pain and the provider does a complete physical exam and discovers that the woman is circumcised and is suddenly making comments like: ”Oh, my God, what happened to you? This is the worst thing I’ve ever seen!” And then a patient in stirrups tries to explain it through an interpreter. All the while, she’s thinking, ”But what about my abdominal pain?” And the fact is, she may or may not have a problem with how her body looks, but she doesn’t want to be judged. Given how she’s treated, it’s possible she’ll never return to that provider again, even if she needs to.

Q. Ideally, how should medical professionals react when they encounter circumcised women?

A. I understand that female circumcision is a horrible act and I empathize with the horror of the doctor, but what I ask is that a physician not reveal their emotions and thoughts to the patient. For people who haven’t ever dealt with this, the whole thing may be difficult to understand. One can say, ”it’s a horrible practice and it needs to be stopped.” But the practice is very different from the patient. The patient may or may not have wanted it herself, or she may be happy with the way her body looks. In any case, she should get sensitive and productive care.

Q. What does your work with the circumcised African women do for you?

A. There are days when I feel so fulfilled. When women come to me and tell me that their pain is gone, when they say ”I didn’t realize that sex didn’t have to be painful,” or they say, ”I had so much fear about delivering my baby and it turned out to be so easy.” Those are certain things I feel really great about.

First published here: July 11, 2000.

Dr Nour’s 2012 TED talk re-emphasises the importance of sensitivity in the clinical management of patients who’ve been cut.